How is cellulitis treated?

Updated: Jun 14, 2019
  • Author: Thomas E Herchline, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

Treatment of cellulitis is as follows:

  • Antibiotic regimens are effective in more than 90% of patients

  • All but the smallest of abscesses require drainage for resolution, regardless of the pathogen

  • Drainage only, without antibiotics, may suffice if the abscess is relatively isolated, with little surrounding tissue involvement

In cases of cellulitis without draining wounds or abscess, streptococci continue to be the likely etiology, [2] and beta-lactam antibiotics are appropriate therapy, as noted in the following:

  • In mild cases of cellulitis treated on an outpatient basis: Dicloxacillin, amoxicillin, or cephalexin

  • In patients who are allergic to penicillin: Clindamycin or a macrolide (clarithromycin or azithromycin)

  • An initial dose of parenteral antibiotic with a long half-life (eg, ceftriaxone) followed by an oral agent

Treatment of recurrent disease (usually related to venous or lymphatic obstruction) is as follows:

  • The cellulitis is most often due to Streptococcus species; daily amoxicillin or a macrolide may be effective for prevention of recurrences. [13]

  • If tinea pedis is suspected to be the predisposing cause, treat with topical or systemic antifungals.

Patients with severe cellulitis require parenteral therapy, such as the following:

  • Cefazolin, cefuroxime, ceftriaxone, nafcillin, or oxacillin for presumed staphylococcal or streptococcal infection

  • Clindamycin or vancomycin for penicillin-allergic patients [14]

  • Broad gram-positive, gram-negative, and anaerobic coverage for cases associated with diabetic ulcers [15]

  • Coverage for MRSA, until culture and sensitivity information become available, for severe cellulitis apparently related to a furuncle or an abscess

For cellulitis involving wounds sustained in an aquatic environment, recommended antibiotic regimens vary with the type of water involved, as follows:

  • Saltwater or brackish water: Doxycycline and ceftazidime, or a fluoroquinolone

  • Freshwater: A third- or fourth-generation cephalosporin (eg, ceftazidime or cefepime) or a fluoroquinolone (eg, ciprofloxacin or levofloxacin)

  • Lack of response to an appropriate antibiotic regimen should raise suspicion for Mycobacterium marinum infection and suggest wound biopsy for mycobacterial stains and culture

See Treatment and Medication for more detail.


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